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Patient Voices Network User Account

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Account Information

Username: *

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E-mail address: *

A valid e-mail address is required. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or certain news or notifications by e-mail. If the email you enter has already been taken, you cannot use this email address. This will be indicated to you when you press the 'Create New Account' button below – the email address will be highlighted in red.

Contact Information

First Name: *

Last Name: *

Organization/Business (if applies):

Address (line 1): *

Address (line 2):

City: *

Province (within Canada):

State/Region (outside Canada):

Country: *

Postal/ZIP Code: *

Primary Phone: *

Secondary Phone - optional:

Demographic Information

Age Range:

Gender:

Ethnicity/Culture:

Would you like to be involved in any of the following options? (Check any that apply)

Join our email list (you can unsubscribe at any time)

Train to become a part of a team of BC- wide peer coaches who will give informal telephone support to individuals who need help in reaching their health goals. (eg. quitting smoking, losing weight, sticking with a fitness program)

Play a role in shaping the changes in primary healthcare in BC by getting actively involved in the system. (eg. participating in a speaker’s bureau, sitting on a Patient Advisory Board, attending conferences and seminars regarding healthcare improvements)

Improve the health of your community by getting involved in identifying health-related issues and working with healthcare professionals and other community members to find appropriate solutions.

How did you hear about the Patient Voices Network?: *

TERMS AND CONDITIONS

Please confirm you have read both our privacy statement and EULA (End User Licence Agreement)

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If you have
any questions
regarding
registration,
please contact
connect@
patientvoices.ca.